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Avoidable Imaging Learning Collaborative: Low Back Pain
Kevin M. Klauer, DO, EJD, FACEP
CMO, EM-TeamHealth
Co-Chair of the Avoidable Imaging Initiative for the E-QUAL Network
Medical Editor-in-Chief, ACEP Now
Asst. Clinical Professor, MSU-College of Osteopathic Medicine
“In actual ED practice, more than 30% of patients with nontraumatic back pain are imaged.”
“A meta-analysis of 1,804 patients from 6 studies who received no imaging versus those with any imaging (spine radiographs or MRI) found no difference in outcomes.”
• Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.
• Adult low back pain, 12th edition. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Sep. 37 p.
• van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST Acute Low Back Pain in Primary Care. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. 2004. Eur Spine J. 2006 Mar;15 Suppl 2:S169-91.
• Australian Acute Musculoskeletal Pain Group. Evidence-based Management of Acute Musculoskeletal Pain. Acute Low Back Pain. Chapters 4 & 9, pg 25-62 and 183-188. 2003.
• Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults -an evidence-based approach part 3: spinal disorders. J Manipulative Physiol Ther. 2008 Jan;31(1):33-88.
• Tracey NG, Martin JB, McKinstry CS, Matthew BM. Guidelines for lumbar spine radiography in acute low back pain: effect of implementation in an accident and emergency department. Ulster Med J. 1994 Apr;63(1):12-17.
Additional Resources
KNOWLEDGE TRANSLATION TAKING IT TO THE BEDSIDE!
Presenters
Shawna Laursen, MD Dr. Thomas Wetjen, DO
Utilization of Medical Imaging
July 21, 2016
Thomas Wetjen, DO
Kennedy Health System – located in Southern New Jersey Three hospital health system with an ED Volume of
approximately 140,000 visits annually
Community based health system with a residency program in Emergency Medicine
The ED’s are constantly challenged by our Utilization Management Committee to reduce usage of medical imaging Department of Radiology and the Emergency Department
decided to approach the problem via a systems approach
The first performance improvement project was low back pain and medical imaging
The Emergency and Radiology Departments agreed that reducing medical imaging of the lumbar spine for our population would result in reduced healthcare costs and would benefit patients by reduced radiation exposure
Objective: To reduce the usage of medical imaging for atraumatic low back pain in the ED
Methods: To provide education to our team of medical providers (attending physicians, resident physicians, and APC’s) in regards to their approach to medial imaging and back pain. The education was disseminated via a computer based learning module. All emergency providers had to attest to studying the materials via a post test.
Methods Continued: The Emergency Department Directors collaborated with the Department Head of Radiology and approved the materials and criteria for medical imaging
The next few slides are highlights of the educational materials which were introduced at the end of April 2016
The association between symptoms of mechanical low back pain (LBP) and imaging results is weak. Ordering of imaging studies should be limited to patients with clinical findings suggestive of systemic disease (eg, fever, weight loss without explanation, patients older than 50 y, alcohol use, or intravenous drug abuse) or trauma.
Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patients have severe or progressive neurologic deficits or are suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an X-ray or CT scan.
Too many diagnostic x-rays are ordered in the evaluation of low back pain at all three Kennedy Emergency Departments
Uncomplicated acute low back pain and/or radiculopathy are benign, self-
limited conditions that do not warrant any imaging studies. Significant (major) trauma - CT is the modality of choice. If a CT of the
chest, abdomen and pelvis have been performed – 2D reconstructions are sufficient, and dedicated thoracic and lumbar CT’s are not necessary. CT can be performed in conjunction with MRI and MRI may be preferred in
suspected ligamentous and or cord injury.
MRI of the lumbar spine should be considered for those patients presenting
with red flags raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, or infection.
Results:
*Codes: Spine Lumbo Sacral Ant/Lat and Lumb A/P and Lat
Results:
Pre-Intervention (January – April 2016)
1258/49254 or 25.5 patients per 1000 visits received a diagnostic x-ray of their lumbar spine
Post-Intervention (May – June 2016)
412/24821 or 16.6 patients per 1000 visits received a diagnostic x-ray of their lumbar spine
Represents a 35% reduction of diagnostic x-rays performed for the evaluation of low back pain
Reducing
Imaging in Low
Back Pain Shawna Laursen, MD
Medical Director Skagit Valley Emergency Department
Mt Vernon, WA
Choosing Wisely
The Choosing Wisely (www.choosingwisely.org)
campaign was created as an initiative of the American
Board of Internal Medicine (ABIM) foundation to
improve health care quality.
More than 50 specialty societies have identified
commonly used tests or procedures within their
specialties that are possibly overused.
One such test is Imaging for Low Back Pain
Low back pain is the presenting complaint
for almost 3 million annual ED visits and
2.5% of all outpatient clinic visit in the US
Over 30% of these visits have x-rays ordered
Multiple guideline and consensus recommendations recommend: Don’t do imaging for low back pain within the first 6 weeks unless red flags are present
Red Flags include but not limited to: Severe or progressive neurologic deficits (e.g., bowel or bladder function, saddle parasthesia), Fever, Sudden back pain with spinal tenderness (especially with history of osteoporosis, cancer, steroid use), Trauma, Serious underlying medical condition (e.g., cancer)
Choosing Wisely www.choosingwisely.org
US Department of Health and Human Services
AHCPR Clinical Practice guideline: Acute Low Back
Problems in Adults http://d4c2.com/d4c2-00038.htm
Institute for clinical Systems Improvement. Adult
Acute and subacute Low Back Pain www.icsi.org/_assset/bjvqrj/LBP.pdf
Clinical Efficacy Assessment Subcommittee of the
American college of Physician and the American
College of Physicians/American Pain Society Low
Back Pain Guidelines Panel Ann Intern Med. 2007;147: 478-491
AAFP Clinical Practice Guideline: Low Back Pain AAFP, endorsed February 2011
What did we do and how
did we do it?
Medium size community hospital, 33K/yr ED visits,
level 3 trauma center
Started with provider education, group discussion at
staff meeting, distribution of guidelines
Provider participation in chart review to establish
baseline rates of imaging.
Provider participation
key Having providers do chart review means they know
the review is happening (more than just another email)
They have to be aware of the guidelines to complete review
They see how their partners are charting which tends to standardize practices
They tend to adhere to guidelines knowing their partners will be reviewing them in the near future
Forces engagement rather than just acknowledgement
How to get provider
buy-in
Pay them for doing the review (we include chart
reviews in quarterly bonus structure)
Make the review itself easy (each provider was given
20 records that were coded as low back pain, asked if
red flags present, if no red flags, was imaging done)
Give provider specific feedback and name names (no
one wants to be the outlier)
The Hawthorn Effect
The Hawthorne effect (also referred to as the observer
effect) is a type of reactivity in which individuals
modify or improve an aspect of their behavior in
response to their awareness of being observed.
Let psychology work for you
Repeat the chart review after period specified
Summarize and report back results to providers
Our Method Initial Chart review done in November 2015.
Education and discussion regarding evidence based guidelines for use of imaging in low risk low back pain followed. Follow up chart review was done in May 2016
“We will be reviewing Low Risk Low Back Pain seen in the ER to determine our initial rate of imaging. We will be discussing this at our ED Department meeting and asking all providers to review guideline recommendations. A review will be repeated in 6 months to see if our imaging rate is altered as awareness of and compliance with national guidelines is encouraged. “
Our Findings
0.77
0.93
0.23
0.07
0
0.2
0.4
0.6
0.8
1
Initial Review % Follow up Review %
no imaging %
imaged %
47
14 5
0
20
40
60
80
Initial Reveiew Follow Up Review
no imaging
imaged
Bottom line: We had a 70% reduction in overall imaging for low risk low
back pain with education, use of evidence based guidelines and provider
involvement in chart review
Questions?
Avoidable Imaging Initiative Webinar:
Thursday August 18
1:00pm-2:00pm EST
E-QUAL Network Resources and More Information: www.acep.org/equal
Contact Nalani Tarrant (Project Manager):